The sample size calculation is based on data shared with the study team from each BSO regional lead team in the OH West region to estimate the total population of BSO staff and leadership (personal communication, 2024). The following criteria were used to estimate the sample size: a 10% dropout rate, power of 80%, and a statistical significance level of α=.05 [18]. This resulted in a total target sample size of 280 participants to complete the survey in phase 1 of this study.

The target sample size for interviewees and focus group attendees will differ depending on the participant group, with a total target sample of up to 120 participants (up to 24 care partners and up to 96 BSO service providers or leadership) across the OH West region (Table 3).

A probability sampling approach will be used in phase 1 to recruit participants. Participant recruitment for phase 1 (anonymous survey) will occur through email and in-person meetings. Each BSO region’s regional lead team will distribute a study recruitment email to all BSO staff, leaders, and other eligible participants for whom they have contact information. This email will include details about the study, invite BSO service providers and leaders to participate in an optional brief survey, and inform them that they are able to participate in either phase 1 or phase 2, or both, of the study. In addition, each BSO regional lead team will provide brief details about the study and how to complete the phase 1 survey during pre-existing meetings, presentations, and other sessions. Implied consent to participate will be obtained during the initial questions of the survey.

A maximum variation purposeful sampling technique [19] will be used in phase 2 to recruit participants for focus groups and individual interviews. Recruitment of BSO staff, leaders, and other health care providers who work with the BSO program will occur through email and in-person meetings. For BSO staff and leaders, details on how to volunteer for a focus group or interview will be included in the recruitment email distributed by each region’s BSO operations team, as described earlier. Staff and leaders will be able to notify the research team of their interest in taking part in a focus group or interview by entering their name, contact information, care setting (ie, LTC, community, or acute care), and whether they are staff or leadership into a contact form; the contact form can be accessed at the end of the anonymous survey in phase 1 or via a direct link. The research team will screen interested individuals and invite those who are eligible to participate in a focus group or individual interview, based on the participant’s stated preference, provided that the target sample size has not been filled for their region and participant group type. Before conducting the focus group or interview, participants will complete a brief demographic questionnaire to provide details about their background with BSO. Written consent to participate will be obtained digitally before completing the demographic questionnaire.

Family care partner recruitment for phase 2 interviews will occur in three ways: (1) email, (2) in person, or (3) a recruitment poster. A study recruitment email, including brief details about the study and information on how to participate in an interview, will be sent to BSO family care partners by either the applicable region’s BSO operations lead or an associated agency that supports BSO family care partners (eg, Alzheimer’s Society and adult day programs). Alternatively, the BSO staff will provide study information and a recruitment poster to eligible care partners. In addition, the study will be advertised by BSO staff using a visual recruitment poster with applicable study information and contact details in locations that BSO care partners frequent (eg, public locations in LTC homes and community offices). In each recruitment method, interested care partners will be required to contact the research team directly to begin study activities. Once contact is initiated, a member of the research team will explain the study in detail to the care partner and answer any questions. If the care partner is interested in participating, the researcher will walk them through the letter of information and consent form and obtain verbal consent. Before conducting the interview, care partners will complete a brief demographic questionnaire to provide details about their background with BSO.

Data will be collected in three phases: (1) anonymous online survey, (2) focus groups and individual interviews, and (3) secondary data use. Focus groups and interviews with family care partners will occur either off-site (care partners will have the choice of an in-person interview at a local health care area) or in a Microsoft Teams meeting for a period of 9 months. Focus groups and individual interviews with BSO staff, leaders, and other health care providers will be conducted using the Microsoft Teams platform. Data will be collected by the researchers, and the principal investigators will oversee the data collection process. In phase 1, survey data will be collected; in phase 2, focus group and individual interview data will be collected; and in phase 3, secondary data from the BSO PCO will be obtained for analysis.

BSO service providers (ie, staff and leadership) and other health care providers who support BSO from across the OH West region will be invited to participate in an anonymous online survey, hosted by Qualtrics. It is expected that it will take approximately 10 minutes to complete the survey and is accessible from any device with internet access (ie, smartphone, computer, and tablet). Survey participants will be asked demographic questions, including age, ethnicity, gender identity, professional designation (eg, nurse, personal support worker, physician, or management), sector of employment (ie, LTC, hospital, or community), the number of years practicing in their role, the number of years working with BSO, and their BSO region. Participants will also be asked a mix of scale-based and open-ended questions created by the research team to understand their perspectives on several factors related to the BSO program, including support for patients, family care partners, and staff; clarity of the BSO program in general; and relations with other BSO members and the regional lead team in their region. At the end of the survey, participants will be automatically routed to a separate form to sign up for an interview or focus group session, if they are interested. Participants will not be reimbursed or compensated for their time to complete the survey.

BSO staff and leaders and BSO-adjacent health care providers who indicate their interest will be contacted by the research team to participate in an individual semistructured interview or a focus group. Semistructured interviews will take approximately 30 to 45 minutes to complete, and focus group sessions will take approximately 1 to 1.5 hours and include up to 8 participants per focus group. It is expected that 2 members of the research team will attend each interview, while 2 members of the research team will attend each focus group to facilitate the group discussion. All interviews and focus groups will be recorded and automatically transcribed using Microsoft Teams. Before the interview or focus group, participants will be asked to complete a demographic questionnaire to provide information about their age, ethnicity, gender, professional designation (eg, nurse, personal support worker, physician, or manager), sector of employment (ie, LTC, hospital, or community), the number of years practicing in their role, number of years working with or collaborating with BSO, and region. During the interview or focus group, participants will be asked about their own experiences with BSO, observations related to the impact of BSO on patients and family care partners, and suggestions for improving BSO in the future.

Family care partners who indicate their interest in the study will be invited to participate in a semistructured interview with a member of the research team, which will take approximately 30 to 45 minutes. Interviews will be conducted over Microsoft Teams, by phone, or in person, based on each participant’s preference. Following the verbal consent process and before the interview, participants will be asked to complete a demographic questionnaire to understand their age, gender, ethnicity, and caregiving situation. During the interview, participants will be asked about their experiences with BSO programs and services, observations of how BSO affected the older adult with responsive behaviors, and suggestions for improving BSO in the future. All interviews will be recorded and transcribed using Microsoft Teams.

To contextualize the findings from phases 1 and 2, the BSO PCO has agreed to provide regional administrative data for the past 5 fiscal years (FY 2019–2020 to FY 2023–2024) for the 4 OH West BSO regions. These data will provide information regarding each BSO region’s volumes of family care partners and patients and residents supported in each care sector (ie, LTC, community, and acute care), care coordination, capacity-building efforts, and system navigation support for BSO care recipients.

Survey data will be managed and analyzed using SPSS (version 29; IBM Corp). Raw data will be screened before analyses to (1) investigate the integrity and accuracy of the data collected by identifying and removing spam and bot responses [20,21]; (2) identify, examine, and address outliers; (3) identify, examine, and address missing data; and (4) assess the statistical distribution of the data, including measures of linearity, homoscedasticity, normality, and collinearity. Cleaned data will be analyzed using descriptive and inferential statistical techniques. Descriptive statistical analyses will be conducted to create a profile of survey participants, including both personal and professional demographics, and their standing on BSO’s impact on staff, patients, and family care partners. Four-way ANOVA and factorial ANOVA will be used to identify interregional differences in continuous variables. Correlational and multiple regression analyses will be conducted to examine the relationships among the variables. Subgroup analyses will include examining differences based on sector and role type (staff or leader). Where possible, data will also be stratified based on participants’ recency of BSO interaction and the length of time spent directly or indirectly supporting the provision of BSO services.

Qualitative analysis will be conducted using an interpretive descriptive approach [22]. Interpretive description is an inductive analytic approach used to identify and provide meaningful explanations of thematic patterns in participants’ experiences with clinical services, making it a suitable lens for analyzing the experiences of staff, leadership, and family care partners with BSO. All interview and focus group transcripts will be managed and analyzed using NVivo 14 (QSR International). At least 2 researchers will independently analyze the data to ensure reliability in coding. Data analysis will consist of line-by-line coding, followed by the identification of themes using a clustering technique [23,24]. Given the gendered nature of caregiving and health care workers, codes will be created for gender identity in our analysis [25,26], and their relationships with other themes will be examined. In addition, codes will be created for the length of time spent directly or indirectly involved with BSO services to understand the relationship between longevity and recency of a participant’s BSO interaction with other themes. If saturation is reached, that is, the point at which few or no new relevant ideas or understandings are generated from participants, no further interviews or focus groups will take place [27].

Secondary data provided by the BSO PCO will be analyzed using descriptive and inferential statistical techniques. Descriptive statistical analyses will be conducted to describe BSO activity in the OH West region overall, and the activity of each regional BSO team (ie, ESC, SW, WW, and HNHB). Correlational and multiple regression analyses will be used to examine the relationship among variables. Repeated-measures ANOVA will be used to identify any statistically significant differences in BSO activity over time in OH West and the 4 regions.